On this page
Referral and warning signs
When to refer
Refer AOM if: No improvement after 48-72h antibiotics, Severe symptoms, Signs of complications (mastoiditis, facial palsy, vertigo), Recurrent AOM (>=3 in 6m or >=4 in 12m). Refer CSOM if: Complications suspected (mastoiditis, cholesteatoma), Hearing loss significant, Discharge persists despite weeks of topical treatment/aural toilet, Need for surgical intervention (e.g., tympanoplasty).
Red flags
- Severe ear pain unresponsive to analgesia.
- Swelling/tenderness behind the ear (Mastoiditis).
- Facial weakness/drooping.
- Vertigo/dizziness.
- Stiff neck / Altered consciousness (Meningitis).
- Foul-smelling discharge with debris (Cholesteatoma suspicion).
Signs and symptoms
- Acute Suppurative Otitis Media (AOM):
- - Ear pain (otalgia) - often sudden onset, severe, throbbing.
- - Fever.
- - Irritability, poor feeding, disturbed sleep (infants/young children).
- - Hearing loss (temporary, conductive).
- - May have preceding URTI symptoms.
- - Otoscopy: Bulging, red tympanic membrane (TM), loss of landmarks. May see perforation with purulent discharge if TM ruptures.
- Chronic Suppurative Otitis Media (CSOM):
- - Persistent or recurrent painless ear discharge (otorrhoea) for >14 days through a TM perforation.
- - Discharge may be mucoid or purulent, sometimes foul-smelling.
- - Hearing loss (conductive).
- - Generally no fever or pain unless acute exacerbation.
- - Otoscopy: Visible TM perforation, discharge in middle ear/canal.
Risk factors
- AOM: Young age (<2 years), Daycare attendance, Formula feeding (vs breastfeeding), Passive smoking, Craniofacial anomalies, Immunodeficiency, URTI exposure.
- CSOM: Recurrent AOM, Poor socioeconomic conditions, Eustachian tube dysfunction, Underlying conditions (cleft palate, Down syndrome).
Diagnosis
Clinical assessment
AOM: Based on acute onset of symptoms (ear pain, fever) AND otoscopic findings (bulging, red TM +/- perforation/discharge). CSOM: Based on history of chronic discharge (>14 days) AND otoscopic finding of TM perforation.
Investigations
- Otoscopy is essential.
- Pneumatic Otoscopy (assess TM mobility - reduced in AOM/OME).
- Tympanometry (assess middle ear pressure/effusion - specialist).
- Swab of discharge (CSOM) for Culture & Sensitivity.
- Audiometry (assess hearing loss, especially in CSOM).
Diagnostic criteria
AOM: Acute symptoms + Otoscopic signs of middle ear inflammation/effusion. CSOM: Chronic discharge (>14d) + TM perforation.
Differential diagnosis
- Otitis Externa (pain on pinna movement, canal inflammation).
- Otitis Media with Effusion (OME/'Glue Ear') (fluid behind intact TM, no acute inflammation signs).
- Referred pain (dental, TMJ, pharyngeal).
- Foreign body.
- Cholesteatoma (complication of CSOM).
Management
Non-pharmacological management
- AOM:
- - Pain relief.
- - Observation ('watchful waiting') for 48-72h MAY be considered for uncomplicated AOM >2yrs if mild symptoms and reliable follow-up (not standard UCG approach).
- CSOM:
- - Aural Toilet (Dry Mopping/Wicking): Crucial. Regular cleaning of discharge from ear canal TID until dry. Use rolled absorbent cloth/gauze. Avoid water entry into ear.
- - Keep ear dry during bathing/washing.
- - Address underlying factors (adenoids, allergies - if relevant).
Pharmacological treatment
- AOM: (LOC: HC2)
- - Analgesia: Paracetamol 10-15 mg/kg Q6H PRN OR Ibuprofen 5-10 mg/kg Q6-8H PRN.
- - Antibiotics (Standard): Amoxicillin 40-45 mg/kg/dose PO BID (or 15 mg/kg TID as per UCG table) for 5 days (UCG) or 7-10 days (international). Adult dose: 500mg TID.
- - Alternative (Penicillin allergy): Erythromycin 10-15 mg/kg/dose PO QID. Adult dose: 500mg QID.
- - (Note: High-dose Amoxicillin 80-90mg/kg/day often used internationally, especially if resistance suspected).
- - Follow up in 5 days.
- CSOM: (LOC: HC3)
- - Topical Antibiotic/Antiseptic Drops: After thorough dry mopping.
- - First line: Ciprofloxacin 0.3% ear drops, 2-4 drops TID for 2-4 weeks.
- - Alternatives: Acetic acid 2%, Gentian violet (if fungal suspected).
- - Systemic Antibiotics: GENERALLY NOT indicated or effective for uncomplicated CSOM, unless acute exacerbation or complication.
- Management of Complications:
- - Mastoiditis: IV antibiotics, referral (See ENT006).
- - Meningitis, Abscess: Urgent referral, IV antibiotics, potential surgery.
Monitoring
AOM: Follow up 5 days (or sooner if worsening). Assess symptom resolution. CSOM: Follow up regularly (e.g., weekly initially) to monitor discharge, reinforce aural toilet, continue drops until ear dry for several weeks.
Complications
- AOM: TM perforation, Mastoiditis, Hearing loss (conductive, usually temporary), Facial nerve palsy, Labyrinthitis, Meningitis, Brain abscess (rare).
- CSOM: Hearing loss (conductive, potentially permanent), Mastoiditis, Cholesteatoma (destructive skin growth in middle ear), Intracranial complications (rare).
Prevention
- Pneumococcal (PCV) and Haemophilus influenzae type b (Hib) vaccination.
- Exclusive breastfeeding.
- Avoidance of passive smoking.
- Treating URTIs appropriately.
- Good hygiene.
Patient education
- Explanation of AOM vs CSOM.
- Importance of completing full antibiotic course for AOM.
- Pain relief measures.
- CSOM: CRITICAL importance of regular, thorough ear cleaning (dry mopping) and keeping ear dry. How to instill drops. Chronic nature.
- Recognizing complications needing urgent review.
- Prevention strategies.
Uganda-specific notes
Both AOM and CSOM are very common. AOM often treated with 5-day Amoxicillin course. CSOM management relies heavily on meticulous aural toilet (dry mopping) as access to suction is rare. Ciprofloxacin drops are standard. Complications like mastoiditis occur.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.1.4
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.3.5 (IMCI Ear Problem algorithm)